In mid-2018, Paula Lazarus sat in a UCI Health gastroenterologist’s office and couldn’t believe what she was hearing. Her previously diagnosed fatty liver disease had progressed to a life-threatening condition called nonalcoholic steatohepatitis (NASH) and severe liver cirrhosis. Dr. Carlos Saad delivered the bad news.
“He said my only hope was to lose weight,” Lazarus, 57, recalls. “It was a scared-straight moment.”
It also changed her life. With the aid of Saad, gastroenterologist Dr. Kenneth Chang, executive director of the UCI Health Digestive Health Institute (DHI), and her family, Lazarus began a journey that has culminated in a 100-pound weight loss and dramatically improved her liver health.
“At this stage, my next step is to share my experience and give hope to people with NASH, cirrhosis and other weight-related health issues,” says Lazarus, who has led a lupus support group and helped newly diagnosed patients for more than 15 years. “If I can do it, anyone can.”
Technology to gauge liver disease
She considers herself lucky to have found DHI, one of the nation’s most forward-thinking gastrointestinal treatment centers. DHI pioneered the breakthrough device that helped diagnose her liver condition.
DHI’s guiding philosophy is to address the underlying causes of gastrointestinal disorders — from GI cancers to gastrointestinal reflux disease. Obesity is often a contributing factor to many GI diseases, says Saad, an associate professor in the UCI School of Medicine’s Division of Gastroenterology. That’s why the institute has made prevention and treatment of obesity a central focus of its mission.
“More than 40% of Americans suffer from obesity,” Saad says. “It is the No. 1 cause of fatty liver disease and NASH. And we know who is at highest risk for developing those conditions: people who are insulin resistant or prediabetic, who have a large waist circumference and high levels of triglycerides, high blood pressure or high blood sugar.”
Lazarus’s weight had yo-yoed for most of her adult life. In her 50s, she reached a high point in her struggle, causing her community doctors at the time to express their concern.
“They told me I had fatty liver disease, that I needed to lose weight,” she says. “At the time, I was very heavy. You obviously know you need to lose weight. It’s not that you don’t take it seriously, but I had no idea it could lead to cirrhosis of my liver.”
Lazarus, who has other chronic health problems, including lupus, tried unsuccessfully to lose weight on her own. “Exercise has been difficult for me because of my lupus-related pain. My eating habits also needed to improve. And I was on medications that cause weight gain, so it was a real battle.”
Silent condition turns deadly
But her doctors didn’t tell her that nonalcoholic fatty liver disease, a silent condition estimated to affect 80 million Americans, could progress into something life-threatening. NASH is characterized by liver inflammation due to an accumulation of fat. As it did for Lazarus, NASH can cause cirrhosis, a scarring of the liver that impairs its function. In severe cases, the only treatment is a liver transplant.
When Lazarus had to change her health insurance for 2018, she decided to switch to UCI Health, which led her to Saad. He immediately ordered a battery of tests to assess her liver. The most important one was an endoscopic ultrasound-guided portal pressure gradient — or EUS-guided PPG — test that Chang developed.
The test evaluates liver blood pressure, a critical measurement to assess liver health. Before Chang developed the test, it was almost impossible to get an accurate blood pressure reading for the liver without an invasive procedure. Chang, who specializes in interventional endoscopy for esophageal and gastrointestinal disorders, is now helping to train physicians worldwide in the use of EUS-guided PPG. He will demonstrate the device and technique at DHI's 13th annual Gastroenterology and Hepatology Symposium in April.
“Dr. Chang is a visionary,” Saad says. “He knew early on that measuring the pressure gradient is the single best prognostic indicator of liver disease, so he helped develop this technique. UCI is the right environment for such people to make things that are of worldwide importance.”
Lazarus was impressed that her UCI Health doctors could gauge her liver health in so sophisticated a manner. “The result was so much more informative than the previous biopsies I’d undergone. I am so grateful this technology is available.”
Finding help to lose weight
Once Lazarus was diagnosed with NASH and cirrhosis, she knew she had to shed the excess pounds. She saw Chang to discuss her options. She chose to undergo endoscopic sleeve gastroplasty, a procedure in which a flexible tube fitted with a camera and suturing device is inserted through the mouth into the stomach to reshape and reduce its size. Studies show gastroplasty makes patients feel full faster and limits food intake.
Lazarus was disheartened when her insurance carrier would not cover the procedure. But her family stepped in to pay the cost. The procedure, itself, was easy, she recalls. Changing her eating habits took grit and determination. The first stage of her post-procedure diet consisted of 30 days of protein shakes.
“I really didn’t think I could do it, but I made a commitment to myself that I had to find a way,” she says. “I did not want to die.”
Lazarus sees June 24, 2019, as the kickoff of a football game. Chang, whom she calls “a genius and a savior,” performed the sleeve gastroplasty. Lazarus had to catch the ball and run with it. Today, she can say the result was a touchdown.
“The procedure is life-changing, but it is only a tool, not a magic bullet,” she says. “I had to eliminate sugar and learn to watch other people eat things I could not. I had to deal with emotional eating and completely change my relationship with food. There were many other obstacles along the way that anyone trying to lose weight encounters.”
Her mother, Sue Allie, was her “rock,” keeping her daughter’s spirits up and holding her accountable. And a friend who’d had the same procedure gave her a great tip: sugar-free popsicles. “They saved me many times.” She has now lost 100 pounds — 20 before the surgery and 80 since.
Regaining liver health
Best of all, her liver is recovering. Tests, including another EUS-guided PPG check in March 2020, showed that her high liver blood pressure had normalized and that the fat in her liver was gone. Saad said the cirrhosis had stabilized and may begin improving over time.
Saad says just telling patients like Lazarus to diet and lose weight isn’t enough. “We reinforce to our patients the health risks of continued obesity. That is when patients truly make the leap to say, ‘OK, doctor, help me achieve my goal.’ We have a responsibility to be more proactive with our patients.”
Lazarus’ overall health has improved significantly. “It has given me more confidence,” she says. “I feel better about myself. At the high point of my weight gain, I was starting to isolate because I was ashamed about how heavy I was. To have that burden gone is huge.”
Her joints feel better and her closet has been thinned — with bags of clothes donated to thrift shops.
By the end of 2020, she had maintained her goal weight for more than six months. “It took a team of exceptional and supportive doctors, my family and friends to help me save my life. I will be forever grateful.”
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